Components of the Coherent Psychiatric Frame
The purpose of the therapeutic frame is to protect the patient’s safety and to promote recovery. It is the therapist’s responsibility to structure the frame through word and deed. Langs (1984–1985) stressed that a healthy and secure therapeutic environment is predicated on reducing variability and uncertainty in the treatment setting as much as possible. Table 5.6 summarizes the major boundary factors comprising the coherent treatment frame. Careful attention to these boundary issues can assist treating psychiatrists to communicate defining messages that strengthen the differentiation of role and identity between patient and practitioner.
The diversity of opinion regarding optimal methods of treatment for specific psychiatric disorders makes it very dif-ficult to devise a set of specific guidelines that are appropriate for psychiatrists adhering to a wide spectrum of theoretical orientations. Dyer (1988, pp. 45–57) emphasized how problem-atic it is to define a comprehensive ethical system, whether it is based on a set of specific rules (deontological ethics), on a list of values and goals (teleological ethics), or from consideration of the emotional and practical consequences of a given course of action (consequentialist ethics). A parallel dilemma exists when it comes to defining psychiatric boundaries. For this reason, guidelines for psychiatrists should enhance patient safety, fos-ter adherence to established clinical principles, and help to avoid specific consequences that are detrimental to either patient or practitioner. Such an approach is consistent with an intensifying interest in reducing preventable medical error. In his seminal work on human error, Reason (1990, p. 69) outlined three major types of performance as a way to address the sources of preventable human error. These categories include rule-based performance, skill-based performance and knowledge-based performance. As an example, Reason described how the use of inadvisable rules leads to rare but preventable collisions at sea, citing studies re-porting how experienced maritime pilots expose themselves and others to unnecessary and potentially serious risk by allowing their own vessel to navigate too closely to adjacent ships even when there is plenty of sea room to avoid such proximity:
The confidences these and other experienced operators have in their ability to get themselves out of trouble can maintain inad-visable rule behavior. This is particularly so when a high value is attached to recovery skills and where the deliberate courting of a moderate degree of risk is seen as a necessary way of keep-ing these skills sharp.
With regard to rule-based procedures for reducing error in psychiatric practice, each boundary issue can be exam-ined from the point of view of clearly indicated procedures, relatively risky procedures and contraindicated procedures (Epstein, 1994, pp. 113–117). In the ensuing discussion of com-ponents of the psychiatric frame, lists of these various types of procedures are adapted from Epstein’s earlier work on boundaries (Epstein, 1994, pp. 119–236).
Riskier procedures that fall into the “gray zone” are not necessarily unethical or unsound. However, psychiatrists engag-ing in such activities should be aware of the circumstances under which they increase or reduce the chance for injury either to the patient or themselves. For example, under most conditions, it is probably unwise to attempt psychiatric treatment of one’s next-door neighbor. Nevertheless, practitioners living in remote areas or working in confined ethnic communities might, as a matter of practicality, be forced to treat such a patient for whom no reason-able alternative exists. The hazard of no treatment may outweigh other factors in the situation. However, the fact that psychiatrists sometimes must treat patients under risky circumstances does not mean they should disregard the increased hazard they areassuming or forget about optimal treatment standards, just as the exigencies of battlefield surgery do not obviate the need to strive for aseptic technique.
Psychiatrists should safeguard against any semblance of inappropriate behavior even if the activity can be justified as seem-ingly harmless. For example, seeking social activities with patients outside of the treatment setting can be interpreted by patients or their family members as seductive. Gutheil and Gabbard (1993) have emphasized that the very appearance of undue familiarity with a patient may, in and of itself, hamper successful defense against false allegations of professional wrongdoing.